Left ventricular diastolic dysfunction attenuates outcomes in chronic thromboembolism pulmonary hypertension
Abstract
Abstract Background Left ventricular diastolic dysfunction in chronic thromboembolic pulmonary hypertension is classically attributed to the negative effects of pulmonary hypertension on left ventricular filling. Recent evidence, however, suggests diastolic dysfunction may exist independent of pulmonary hypertension and moreover may be masked by an under-filled left ventricle. Methods Consecutive patients undergoing pulmonary endarterectomy (2007 – 2018) were included (n=1266). Left ventricular diastolic dysfunction was assessed using pulmonary arterial wedge pressure and in nested cohorts utilising multi-modal cardiac imaging. Diagnostic baseline, outcome data, and long-term mortality outcomes were assessed. Results 135 individuals had a wedge pressure >15mmHg following surgery, of whom 60% had a normal wedge pressure pre-operatively. No patients had a formal diagnosis of heart-failure preserved ejection fraction. Haemodynamic, functional and patient-related outcomes were all worse in this patient subgroup and associated with a higher requirement for peri-operative non-invasive ventilation and impaired long-term survival. Post-operative cardiac imaging confirmed evidence of left ventricular diastolic dysfunction in patients with an elevated wedge pressure. Pre-operative left atrial dilatation alone predicted post-operative wedge elevation with accuracy (sensitivity 67%, specificity 100%), and was superior to echocardiography. Conclusions Left ventricular diastolic dysfunction is strongly associated with all pulmonary endarterectomy outcome measures, however the majority of patients do not have an elevated wedge pressure pre-operatively and are not diagnosed with heart failure. Standard pre-operative work-up should include assessment for diastolic dysfunction to aid risk categorisation and guide therapy decisions.
Authors 20
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Katherine Bunclark corresponding
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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Rob J. van der Geest Aachen
Leiden University Medical Center
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Leiden University Medical Center, Leiden, Netherlands
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Heartlands Hospital, Birmingham, UK
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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Pulmonary Hypertension service, Royal Free Hospital, London, UK
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Pulmonary Vascular Unit, Freeman Hospital, Newcastle Upon Tyne, UK
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Pulmonary Hypertension service, Hammersmith Hospital, London, UK
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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Golden Jubilee National Hospital
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Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
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Sheffield PVDU, Royal Hallamshire Hospital, Sheffield, UK
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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PVDU, Royal Papworth Hospital, Cambridge, U.K
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University of Cambridge · Royal Papworth Hospital
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PVDU, Royal Papworth Hospital, Cambridge, U.K
VPD Heart & Lung Institute, University of Cambridge, UK
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